Citation Nr: 1414162 Decision Date: 04/01/14 Archive Date: 04/11/14 DOCKET NO. 10-06 204 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an initial disability rating (evaluation) in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from April 1968 to February 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2009 and August 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. In the April 2009 rating decision, the RO granted service connection for PTSD and assigned a 50 percent initial disability rating, effective from March 21, 2007. In the August 2009 rating decision, the RO denied a TDIU. The Board has reviewed the Veteran's physical claims file, as well as the electronic files on the "Virtual VA" system and Veterans Benefits Management System (VBMS), to ensure a complete review of the evidence in this case. At the March 2010 Decision Review Officer (DRO) hearing, the Veteran provided testimony relevant to the appeal. A transcript of the hearing is of record. In November 2011, the Veteran requested a Board hearing; however, after being notified in a February 2012 letter that he had been placed on the list of persons wanting a Travel Board hearing, and advised of other options, the Veteran withdrew the Board hearing request. See March 2012 response to February 2012 letter; 38 C.F.R. § 20.204(e) (2013). Additional evidence consisting of several lay statements has been received since issuance of the January 2014 Supplemental Statement of the Case (SSOC), and was not accompanied by a waiver of initial RO consideration; however, upon review, the Board finds that the lay statements describe psychiatric symptomatology that was already considered by the RO in previously submitted evidence. For this reason, the Board finds that the additional evidence is not pertinent to the appeal; therefore, no waiver is needed, and the Board will proceed with review. 38 C.F.R. §§ 19.9, 20.1304(c) (2013). FINDINGS OF FACT 1. For the entire initial rating period from March 21, 2007, the Veteran's PTSD has been manifested by occupational and social impairment in most areas such as work, family relations, judgment, thinking, and mood due to psychiatric symptoms of suspiciousness, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, flattened affect, impaired judgment, impaired abstract thinking, anxiety and depression, hypervigilance, intermittent suicidal ideation, intermittent delusional thought and hallucinations, impaired impulse control, and difficulty adapting to stressful circumstances. 2. The Veteran reported that he had a high school education, has past relevant work experience in truck driving, heavy equipment, and carpentry, and has not worked since 1997. 3. The service-connected disabilities are PTSD, to be rated at 70 percent; bilateral tinnitus, rated at 10 percent; scar of the right long finger, rated at 0 percent; peripheral neuropathy of the right long finger, rated at 0 percent; and bilateral hearing loss, rated at 0 percent. The combined disability rating is 60 percent. 4. The Veteran is unable to secure or follow a substantially gainful occupation solely as a result of the service-connected disabilities. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for an initial rating of 70 percent, and no higher, for PTSD are met for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.126, 4.130, DC 9411 (2013). 2. Resolving reasonable doubt in favor of the Veteran, the criteria for the award of a TDIU have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.340, 3.341, 4.1, 4.3, 4.15, 4.16, 4.18, 4.19 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duties to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice should be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For reasons explained below, the Board is granting a TDIU. Given the favorable outcome of the TDIU appeal, which is a full grant of the benefits sought, the appeal has been substantiated, obviating the need for discussion of how VA fulfilled the duties to notify and assist with respect to that issue. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Board notes that a claim for a TDIU is, in essence, a claim for an increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Norris v. West, 12 Vet. App. 413, 420 (1999). A TDIU claim is an alternative way to obtain a total disability rating without recourse to a 100 percent evaluation under the rating schedule. See, e.g., Parker v. Brown, 7 Vet. App. 116, 118 (1994). Regarding the initial rating appeal for PTSD, the Veteran is challenging the initial disability rating assigned following the grant of service connection in the April 2009 decision. The Court has held that, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has in fact been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess v. Nicholson, 19 Vet. App. 473, 490-91; Dunlap v. Nicholson, 21 Vet. App. 112, 117 (2007). Furthermore, under 38 C.F.R. § 3.159(b)(3)(i), there was no duty to provide the Veteran with VCAA notice upon receipt of a Notice of Disagreement, such as in this case on the issue of initial rating. For these reasons, the Board finds that no further notice, beyond that afforded in the context of the original claims for service connection, is needed under the VCAA. Regarding VA's duty to assist in claims development, the record contains all available evidence pertinent to the appeal. VA has requested records identified throughout the claims process. The Veteran was given appropriate notice of the responsibility to provide VA with any treatment records pertinent to the appeal, and the record contains sufficient evidence to make a decision on the appeal. The complete service treatment records are included in the record, and post-service treatment records identified as relevant to the appeal have been obtained or otherwise submitted. Also, the Veteran underwent multiple VA medical examinations in connection with the initial rating appeal from February 2009 to October 2013. The VA medical examiners provided medical opinions based on an accurate medical history, and considered the Veteran's subjective complaints as it related to his current symptomatology and its effects on his daily life. The VA medical examiners also performed thorough mental evaluation of the Veteran. In consideration thereof, the Board finds that the VA medical examiners had adequate facts and data regarding the history and current severity of the PTSD disability when rendering the medical opinions. See VAOPGCPREC 20-95 (interpreting that the determination as to whether review of prior medical records is necessary in a particular case depends largely upon the scope of the examination and the nature of the findings and conclusions the examiner is requested to provide, so that in some cases an accurate history by a veteran may be a valid basis for an examination report rather than claims file review); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran). There is no allegation or indication that there has been a material change in the condition since the last VA medical examinations. For these reasons, the Board finds that the collective VA medical examinations and medical opinions are adequate for the claims decided herein, and no further medical examination or medical opinion is needed. Neither the Veteran nor the representative has made the RO or the Board aware of any other evidence relevant to the appeal that needs to be obtained. Given the foregoing, the Board concludes that the Veteran has been provided with proper notice and all relevant facts have been properly and sufficiently developed in this appeal. No further notice or development is required. In view of the foregoing, the Board will proceed with review. Disability Rating Legal Criteria Disability ratings are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2, which require the evaluation of the complete medical history of a veteran's condition. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In a claim for a higher original rating after an initial award of service connection, all the evidence submitted in support of a veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. For the entire rating period, the Veteran's PTSD is rated at 50 percent under the criteria found at 38 C.F.R § 4.130, DC 9411. Psychiatric disabilities are evaluated under the General Rating Formula for Mental Disorders. Under the General Rating Formula for Mental Disorders, a 50 percent rating is prescribed when there is evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. A 70 percent rating is provided when there is evidence of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating requires evidence of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The Global Assessment of Functioning (GAF) scale reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the Diagnostic and Statistical Manual of Mental Disorders at 32 (4th ed. 1994)). GAF scores ranging from 71 to 80 reflect that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). GAF scores ranging from 21 to 30 reflect behavior that is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. With regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. The use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list and are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013), the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) determined that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." Thus, the demonstrated symptomatology is the primary focus when deciding entitlement to a given disability rating and a veteran may be entitled to a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Id. Disability Rating Analysis for PTSD After review of all the lay and medical evidence of record, the Board finds that the evidence in equipoise on the question of whether the disability picture associated with the Veteran's service-connected PTSD more closely approximates the schedular criteria for a 70 percent rating under DC 9411 for the entire rating period. On the one hand, with the exception of suicidal ideation, all of the psychiatric symptoms that the August 2013 VA PTSD examiner identified as symptoms of PTSD (i.e., suspiciousness, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, flattened affect, impaired judgment, and impaired abstract thinking) are specifically contemplated in the schedular criteria for a 50 percent rating (or the lesser included 30 percent rating). Also, the August 2013 VA PTSD examiner specifically noted that the effect of PTSD on occupational and social impairment was best described as occupational and social impairment with reduced reliability and productivity, which is the level of occupational and social impairment contemplated in the schedular criteria for a 50 percent rating. Furthermore, VA mental health professionals have also typically assigned GAF scores ranging from 55 to 75 during the rating period, which indicates mild to moderate impairment due to symptoms of PTSD, and this level of impairment is also contemplated by the schedular 50 percent rating. On the other hand, the February 2009 VA PTSD examination report reveals that, in addition to the psychiatric symptoms noted above, PTSD is manifested by symptoms of suicidal ideation, hallucinations of past combat experience, delusional thoughts of a paranoid nature, social isolation with very few quality social relationships, and impaired impulse control (e.g., gambling and impulsively shot a bear that came into his house). The February 2009 VA PTSD examiner assigned a GAF score of 50, and noted that the Veteran was suffering from serious consequences of PTSD. The February 2009 VA PTSD examiner further described the effects of PTSD on occupational and social functioning as PTSD signs and symptoms with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood. The overall disability picture associated with PTSD, as described at the February 2009 VA PTSD examination, is consistent with the schedular criteria for a 70 percent rating. See also April 2008 VA mental health outpatient treatment note (noting the Veteran's report of fleeting thoughts of suicide, wanting to kill a neighbor at times, and hearing voices and seeing things). Also, at the September 2010 private psychological evaluation, the private examiner noted that the Veteran appeared to have had some difficulty handling the stresses and demands of his last job, explaining that the Veteran would become upset with his peers and his alcohol use would interfere with his productivity and ability to be on time. Difficulty in adapting to stressful circumstances (including work or a work-like setting) is another psychiatric symptom contemplated by the schedular criteria for a 70 percent rating. The September 2010 private examiner also assigned a GAF score of 25, which reflects an inability to function in almost all areas and a level of social and occupational impairment specifically contemplated by the schedular criteria for a 70 percent rating (i.e., occupational and social impairment, with deficiencies in most areas). Although the May 2010 VA PTSD examiner opined that there was no occupational impairment due to PTSD, assigned a GAF score of 75, and noted that the effects of substance dependence and secondary gain were prominent throughout the evaluation, and the August 2013 VA PTSD examiner opined that the Veteran's PTSD symptoms were much less problematic than chronic physical pain and memory issues, mental health professionals have not always differentiated between the effects of service-connected PTSD and nonservice-connected substance dependence or physical disabilities; therefore, the Board has considered all possible psychiatric symptomatology as attributable to PTSD in evaluating the current appeal. Mittleider v. West, 11 Vet. App. 181, 182 (1998). In consideration of the foregoing, and resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran's PTSD disability picture more closely approximates occupational and social impairment in most areas such as work, family relations, judgment, thinking, and mood due to psychiatric symptomatology, to include suicidal ideation, impaired impulse control, and difficulty adapting to stressful circumstances; therefore, an initial rating of 70 percent is warranted for the entire rating period. 38 C.F.R. §§ 4.3, 4.7. The Board next finds that the weight of the evidence is against a finding that the PTSD disability picture more closely approximates the criteria for the next higher 100 percent rating under DC 9411 for any period. Although the May 2010 VA PTSD examiner noted that the Veteran had body odor at the examination, the evidence does not establish an intermittent inability to maintain minimum personal hygiene. The VA PTSD examiner in May 2010 answered "No" when asked if the Veteran had an ability to maintain minimum personal hygiene. The weight of the evidence is against a finding that PTSD symptoms, on the whole, are of the frequency, severity, and duration contemplated by the schedular criteria for the 100 percent rating or that PTSD symptoms cause total occupational and social impairment at any time during the rating period. Because the evidence shows that the Veteran has, at various times, denied having suicidal ideation and homicidal ideation (see, e.g., May 2010 VA PTSD examination report and September 2010 VA Emergency Department note), has denied having any plan to commit a suicidal or homicidal act and a history of assaultiveness, the weight of the evidence does not show a persistent danger of hurting self or others. Because the evidence shows some evidence of impaired thinking, but the Veteran has at various times denied having hallucinations and delusions to mental health professionals (e.g., May 2010 VA PTSD examination), the weight of the evidence is against a finding of gross impairment in thought processes or persistent delusions or hallucinations. Because the evidence shows orientation to time and place throughout the rating period, the evidence does not show disorientation to time or place. Although there is some evidence of memory impairment, the evidence does not show memory loss to the degree that the Veteran has not recalled the names of close relatives, his own (former) occupation, or his own name. Furthermore, the evidence does not show total occupational impairment due to PTSD. Rather, as explained below, the evidence shows that the Veteran is unable to work due to the combined effects of the service-connected disabilities, not due to PTSD alone. Also, the evidence does not show total social impairment because the Veteran has maintained good relationships with his sister and daughter throughout the rating period. Because the 100 percent rating specifically contemplates total occupational and social impairment due to PTSD symptomatology, the evidence showing that PTSD symptoms have not caused total occupational or social impairment throughout the rating period weighs against finding that the schedular criteria for a 100 percent rating are met. Extraschedular Consideration The Board has further considered whether the initial rating appeal warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321. Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, it must be determined whether the disability picture is such that the schedular criteria are inadequate, i.e., whether there are manifestations or impairment that are not encompassed by the schedular criteria. If those criteria are not inadequate, the analysis does not need to proceed any further. In this case, the Board does not find any symptoms or functional impairment that is not already encompassed by the current 70 percent rating for the entire rating period. The schedular rating criteria, DC 9411, specifically provides for disability ratings based on a combination of symptoms and clinical findings. For the entire rating period, the Veteran's PTSD is manifested by occupational and social impairment in most areas such as work, family relations, judgment, thinking, and mood due to psychiatric symptoms of suspiciousness, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, flattened affect, impaired judgment, impaired abstract thinking, anxiety and depression, hypervigilance, intermittent suicidal ideation, intermittent delusional thought and hallucinations, impaired impulse control, difficulty adapting to stressful circumstances. The PTSD symptoms demonstrated by the Veteran are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Because the schedular rating criteria is adequate to rate the Veteran's PTSD disability, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). TDIU Legal Criteria Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that he has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16(a). For the purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Id. It is provided further that the existence or degree of non-service-connected disabilities or previous unemployability status will be disregarded where the percentages referred to above for the service-connected disability or disabilities are met and, in the judgment of the rating agency, such service-connected disabilities render a veteran unemployable. Id. Marginal employment shall not be considered substantially gainful employment. For purposes of 38 C.F.R. § 4.16, marginal employment generally shall be deemed to exist when a Veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. Id. A veteran's service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In determining whether unemployability exists, consideration may be given to a veteran's level of education, special training, and previous work experience, but not to his or her age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. A veteran's employment history, his or her educational and vocational attainment, as well as his or her particular physical disabilities are to be considered in making a determination on unemployability. In order for a veteran to prevail in his claim for TDIU, the record must reflect circumstances, apart from non-service-connected conditions, that place him or her in a different position than other veterans who meet the basic schedular criteria. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question is whether the veteran, in light of his or her service-connected disorders, is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). TDIU Analysis In the present case, service connection is in effect for PTSD, now rated at 70 percent; bilateral tinnitus, rated at 10 percent; scar of the right long finger, rated at 0 percent; peripheral neuropathy of the right long finger, rated at 0 percent; and bilateral hearing loss, rated at 0 percent. The combined disability rating is 70 percent. Thus, the Veteran has two or more service-connected disabilities, with one service-connected disability rated at 40 percent or higher (i.e., PTSD), and the combined rating for the service-connected disabilities is 70 percent; therefore, the threshold percentage requirements for the award of a TDIU under the provisions of 38 C.F.R. § 4.16(a) are met. After review of the lay and medical evidence of record, the Board finds that the evidence is in equipoise on the question of whether the Veteran is unable to obtain or maintain substantially gainful employment solely due to the service-connected disabilities. The evidence shows that the Veteran has a high school education, has past relevant work in truck driving, heavy equipment, and carpentry, and has not worked since 1997 due to post-service occupational injuries. See February 2009 VA PTSD examination report. The Board notes that there is some evidence of record showing that the Veteran is unable to secure or follow gainful employment either due to nonservice-connected disabilities or a combination of service-connected and nonservice connected disabilities, but not the service-connected disabilities alone. For example, in September 2010, a private examiner opined that the Veteran was unable to maintain gainful employment due to emotional and physical issues, and listed a number of nonservice-connected physical disabilities on Axis III; however, the private examiner did not include hearing loss, tinnitus, or the right finger disabilities among the disabilities listed. Also, in an October 2010 statement, the Veteran's neighbor wrote that the Veteran performed certain caretaking duties at their home; however, due to physical problems involving the neck and back, and numbness and pain with the use of hand tools, he was unable to accept their offer for a paid caretaking position. More recently, at the August 2013 PTSD VA examination, the Veteran attributed his unemployability to back problems, and not any service-connected disabilities, and the August 2013 VA PTSD examiner opined that the Veteran's unemployability was primarily due to a combination of memory issues and chronic pain, and not one or more service-connected disabilities. On the other hand, there is evidence showing that the Veteran is rendered unemployable solely due to service-connected disabilities. Collectively, the October 2013 VA medical opinions relate that sedentary work was not precluded due to the service-connected disabilities of hearing loss, tinnitus, and the right long finger but would be difficult for the Veteran due to difficulty following multiple instructions, tinnitus symptoms that would become distracting in a very quiet environment, and difficulty using the right hand for gripping, pushing, pulling, or grasping anything with the right hand. Sedentary work would likely require the ability to work in a quiet environment, perform tasks with multiple instructions, and to have manual dexterity of the dominant right hand, which are skills that were noted to be significantly impaired due to the service-connected disabilities by the October 2013 VA medical examiners. Also, the evidence shows that the Veteran's past relevant work experience is in the area of physical labor, not sedentary work, and he has received no training since he stopped working in 1997. When the physical impairments due to service-connected disabilities are viewed in relation to past work experience, education, and training, the fact that the Veteran has an impaired ability to hear, as well as use the dominant right hand, becomes more significant. The evidence further shows that the PTSD disability causes hyperarousal and a pattern of quitting jobs for minor injuries. See February 2009 VA PTSD examination report. For these reasons, and resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran is unable to secure or follow substantially gainful employment solely due to the service-connected disabilities; therefore, a TDIU is warranted. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER An initial disability rating for PTSD of 70 percent, but no higher, is granted. A TDIU is granted. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs